ORIGINAL ARTICLE

Comparison of root resorption after

bone-borne and tooth-borne rapid
maxillary expansion evaluated with the
use of microtomography
Mucahid Yildirima and Mehmet Akinb
Konya and Antalya, Turkey

Introduction: Root resorption was compared between bone-borne and tooth tissue–borne rapid
maxillary expansion patients with the use of microtomography. Methods: The study included 20 patients
(ages 11–16 years) requiring fixed orthodontic treatment who underwent extraction of their first premolars after
rapid maxillary expansion with the use of modified appliances. One side of the appliance covered the teeth with
acrylic, while the other side was fixed to the palatal bone by means of a miniscrew. After 3 months’ retention,
the appliance was removed and teeth were extracted and examined with the use of microtomography.
Results: When the apical, middle, and cervical thirds, as well as the buccal and lingual sides, were compared,
the volume loss was significantly higher in the tooth tissue–borne group than in the bone-borne group (P \0.01).
The least volume loss occurred on the cervical third lingual surface in the tooth tissue–borne group and on the
middle third buccal surface in the bone-borne group. In the former group, least resorption occurred on the
cervical third and highest resorption on the buccal side. In the latter group, surfaces showed no significant
changes. Conclusions: More root resorption occurred in the tooth tissue–borne group, mostly in the apical
and middle thirds. The amount of resorption on the buccal surface was higher than that on the lingual
surface. (Am J Orthod Dentofacial Orthop 2019;155:182-90)

A
n abnormal buccolingual relationship between
the buccal tubercles of maxillary teeth and those
of the mandibular teeth is expressed as posterior
crossbite.1 Rapid maxillary expansion (RME), used in the
treatment of posterior crossbite, is a treatment method
with important orthopedic and orthodontic effects. In
this method, midpalatal suture separation and buccal
tipping over the alveolar base in the teeth are observed
after the expansion force is applied to the maxilla.
Thus, an expansion occurs in the transversal direction
in the upper arch and in the basal bone bearing the
a
Department of Orthodontics, Faculty of Dentistry, Konya Necmettin Erbakan
University, Konya, Turkey.
b
Department of Orthodontics, Faculty of Dentistry, Alanya Alaaddin Keykubat
University, Antalya, Turkey.
Both authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: M€ ucahid Yildirim, Ortodonti AD, Necmettin Erbakan
€
Universitesi Diş Hekimligi Fak€ultesi, 42050, Karatay/Konya, Turkey; e-mail,
mucahidyildirim@konya.edu.tr.
Submitted, September 2017; revised and accepted, March 2018.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2018.03.021
182
alveolar base. The orthopedic effect obtained with the
separation of the midpalatal suture results from applying
a strong force (unilateral 0.9-4.5 kg) over a short period
of time.2 However, because of the heavy forces required
to open the midpalatal suture, buccal tipping and
gingival recession may occur in the abutment teeth
and palatal mucosa, and fenestration in the buccal
bone and resorption in the abutment teeth may occur
as well.3 The idea of expanding the maxilla by providing
only bone support has been suggested by researchers to
minimize such side-effects.3-5
Tooth root resorption occurring after orthodontic tooth
movement is observed as root shortening in the apical re-
gions on x-ray images.6 To date, researchers have exam-
ined the root resorption occurring after orthodontic
treatment with the use of 2-dimensional radiographic
methods,7 histologic methods,8 scanning electron micro-
scopy (SEM),9 cone-beam computerized tomography
(CBCT),10,11 and microtomography (micro-CT).12 It is diffi-
cult to acquire accurate results via 2-dimensional examina-
tions of 3-dimensional (3D) resorption lacunas, although
there are advantages in using this approach, namely,
panoramic and periapical radiographs are commonly
Yildirim and Akin
available, can be used in vivo, and deliver only low doses of
radiation.6 There are disadvantages to the use of SEM, such
as the need for advance preparation and damage to the
dental tissue during such preparations,13 the need for the
extraction of teeth for examination,11 and the impossibility
of obtaining volume measurements.14 Although with the
use of CBCT, images are obtained quickly, have high reso-
lution, and result in a minimal radiation dose compared
with conventional tomography, they have drawbacks,
such as high cost, the presence of methods by which
higher-resolution images can be obtained, their inade-
quacy for the monitoring of dental morphology, and the
fact that they are affected by metal artifacts.15 Micro-CT,
which is regarded as the successor to histologic examina-
tion and which also allows detailed 3-dimensional imaging
of hard tissues, is rapidly becoming the criterion standard
for examining the morphology and contents of hard struc-
tures, such as bone, teeth, and microimplants. Simulta-
neously, compared with a conventional microscope,
which can examine only 2-dimensional images, micro-CT
allows 3-dimensional microscopic imaging.13 The need
for extraction of the tooth to allow micro-CT examination
is the primary disadvantage of the method.11
The aim of the present study was to examine the
amount of root surface resorption occurring in patients
who underwent bone-borne and tooth-borne RME
using a micro-CT device on the premolar teeth that
were extracted after the retention period; and to
compare it with previously published results.
MATERIAL AND METHODS
This study was approved by the Ethics Committee of
the Selcuk University Faculty of Medicine (Number:
2015/28). Patients and their parents provided written
informed consents after having received detailed infor-
mation about the treatment.
The G-Power power analysis program (version 3.1.2;
Franz Faul Universitat, Kiel, Germany) was used to
determine the number of patients required. With the
use of a 0.30 effect size, a 5 0.05 significance level,
2 groups, and 2 repetitive measurements, the sample
size was 20 patients, with an 86% power.
In total, 20 participants (11 female and 9 male,
overall mean age 14.31 6 1.36 years), who applied to
our department for treatment, were included in this
study. The inclusion criteria are listed in Table I.
Patients were primarily treated with the use of a
modified RME appliance. One side of this modified
appliance covers the teeth with acrylic, and the other
side of the appliance is fixed to the palatal bone with a
screw (Fig 1). Furthermore, although the occlusal region
was covered with acrylic on the bonded RME side of the
American Journal of Orthodontics and Dentofacial Orthopedics
183
Table I. Inclusion criteria
Patients aged 11-16 years
No previous orthodontic treatment
Insufficiency in the transverse direction in the maxillary apical base
Indication for extraction of the upper first premolar teeth during
fixed treatment to be performed after rapid maxillary expansion
Indication for extraction of upper first premolar teeth during fixed
treatment to be performed after rapid maxillary expansion
Good oral hygiene
Absence of any oral or systemic disease
Absence of a history of continuous drug use and smoking
appliance, the tooth surface was left open on the side
where the miniscrew was applied. Patients were fitted
with this unilateral occlusion elevated mandibular Essix
plate to prevent expansion of teeth in this region (Fig 2).
Before manufacturing this appliance, Neoanchor Plus
(KJ Meditech, Seoul, South Korea) miniscrews of
1.6-10 mm were applied with an angle of 15
-20

with the occlusal plane 6-8 mm beyond the palatal
gingival margin of the second premolar and first molar
in the palatal region on one side. After the expansion
process, the hyrax screw was stabilized with the use of
a ligature wire. The acrylic appliance was left in the
mouth for 3 months (Fig 3). After this period, the appli-
ance was removed, and fixed orthodontic treatment was
started. The extracted teeth were placed in deionized
water. The teeth were subsequently examined with the
use of a high-definition micro-CT device (Scanco
Medical mCT 50; Bassersdorf, Switzerland) and the
amount of root resorption was calculated from 3D
images with the use of the Mimics program (Materialise,
Leuven, Belgium; Fig 4). The roots were vertically
separated into the buccal and lingual regions,
horizontally separated into the cervical, middle, and
apical third regions with the use of the Mimics program,
and these surfaces were examined. Simultaneously, the
roots segmented in this manner were also examined
on 6 surfaces: the apical third buccal (AB), apical third
lingual (AL), middle third lingual (ML), middle
third buccal (MB), cervical third lingual (CL), and cervical
third buccal (CB) surfaces (Fig 5). Examinations were
performed on the basis of not only absolute volume
loss, but also percentage change. The total volumes of
the root surfaces, the crater volumes of which were filled,
and their crater volumes were calculated with the use of
the Mimics program; the percentage value was obtained,
and further comparisons were made.
Because this study was a thesis study, the first
investigator measured half of the samples in both groups
again in the Mimics program after 3 weeks. The same mea-
surements were repeated by the second investigator. Inter-
and intra-author correlations were observed to be .0.992.
February 2019  Vol 155  Issue 2
184 Yildirim and Akin

Fig 1. Modified rapid maxillary appliance design.

Fig 2. Mandibular Essix appliance.

Data analyses were performed with the use of the
Statistical Package for Social Sciences (SPSS 17.0;
Chicago, Ill). The normality of the data was assessed
with the use of the Shapiro-Wilk test, and it was
determined that the data did not fit the assumptions of
normality. Therefore, nonparametric tests were used in
the analyses. In this study, the Mann-Whitney U test,
Kruskal-Wallis test, and Dunn test were used for the
statistical analyses. P values of \0.05 were considered
to indicate statistically significant differences.
RESULTS
Intragroup comparisons
The results of intragroup evaluation of the volume
differences (mm3) on the surfaces are presented in

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Yildirim and Akin 185

Fig 3. A, Just after the expansion appliances were placed. B, At the end of expansion treatment. C,
After the removal of the expansion appliances.

Fig 4. Determining the amount of root resorption on software program.

Table II. According to the findings obtained, the volume
losses on the AB surface and MB surface were signifi-
cantly different from that of the CL surface (P \0.001)
in the tooth-borne RME group. No significant differ-
ences were observed among the other surfaces
(P .0.05). In the bone-borne group, the volume losses
on the AL surface and on the MB surface were signifi-
cantly different (P \0.01).
The total volume losses occurring on the apical, mid-
dle, and cervical thirds and the buccal and lingual sur-
faces in the tooth tissue–borne group are compared in
Table III. The volume losses occurring in the apical and
middle third were significantly more than that occurring
in the cervical third (P \0.01). There was significantly
less volume loss on the lingual surface than on the
buccal surface (P \0.01). When the same surfaces

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186 Yildirim and Akin

Fig 5. Segmentation of root into 6 pieces.

3
Table II. Results of Kruskal-Wallis tests, used to compare intragroup crater volumes (mm ), and Dunn tests,
for multiple comparisons
Group Surface Mean SD Median Min Max P value Multiple comparison
Tooth tissue–borne AL 0.359 0.395 0.290 0.000 1.700 \0.001* –
AB 0.511 0.430 0.510 0.020 1.500 CL
ML 0.347 0.522 0.015 0.000 1.430 –
MB 0.676 0.637 0.480 0.000 1.980 CL
CL 0.055 0.070 0.015 0.000 0.180 AB, MB
CB 0.300 0.513 0.070 0.000 1.450 –
Bone-borne AL 0.025 0.019 0.020 0.000 0.050 0.010y MB
AB 0.050 0.080 0.015 0.000 0.240 –
ML 0.019 0.037 0.000 0.000 0.120 –
MB 0.009 0.018 0.000 0.000 0.060 AL
CL 0.010 0.021 0.000 0.000 0.070 –
CB 0.015 0.026 0.000 0.000 0.080 –
P \0.05 was considered to indicate statistical significance: *P \0.001; yP \0.01. AL, Apical third, lingual side; AB, apical third, buccal side;
ML, middle third, lingual side; MB, middle third, buccal side; CL, cervical third, lingual side; CB, cervical third, buccal side.

were examined in the bone-borne group, there was no
significant difference between the volume losses on
the various surfaces (P .0.05).
Intergroup comparison findings
A comparison of root resorption in the 6 regions
among the groups is presented in Table IV. The amounts
of volume losses on the MB, AB, AL, ML, and CB surfaces
were significantly greater in the tooth tissue–borne
group than in the bone-borne group (P \0.05). Only
the amount of volume loss occurring on the CL surface
was not significantly different between the 2 groups
(P .0.05).
The results obtained when the root surfaces were
examined as apical, middle, and cervical thirds are
presented in Table V. The amount of volume loss
occurring on each surface was significantly greater in
the tooth tissue–borne group than in the bone-borne
group (P \0.05). However, the amount of volume loss
was significantly greater in the middle and apical thirds
than in the cervical third. The buccal and lingual sides of
the roots are also presented in Table V. The amount of
volume losses occurring on the buccal and lingual
surfaces were significantly greater in the tooth tissue–
borne group than in the bone-borne group (P \0.05).
The total root resorption volumes occurring in the
roots of the teeth are listed in Table VI. According to
these evaluations, whereas the average volume loss
was 2.249 mm3 on the bone-borne side, it was
determined to be 0.128 mm3 on the tooth tissue–
borne side. When the total tooth volume was compared
with the resorption volume, this ratio was found to be
6.285% on the tooth tissue–borne side and 0.392% on

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Yildirim and Akin 187

Table III. Results of Kruskal-Wallis (and Dunn for multiple comparisons) and Mann-Whitney U tests used for intra-
group comparison of volume losses (mm3) occurring on the apical, middle, and cervical thirds and the lingual and
buccal surfaces for tooth tissue–supported and bone-supported sides
Group Surface Mean SD Median Min Max P value Multiple comparison
Tooth tissue–borne A 0.871 0.720 0.745 0.020 3.020 0.008* C
M 1.023 1.047 0.715 0.000 2.910 C
C 0.355 0.535 0.135 0.000 1.580 A, M
L 0.761 0.667 0.560 0.000 2.200 0.010y
B 1.487 1.112 1.265 0.060 4.230
Bone-borne A 0.075 0.094 0.050 0.000 0.290 0.059 –
M 0.028 0.045 0.000 0.000 0.140
C 0.025 0.030 0.010 0.000 0.080
L 0.054 0.051 0.040 0.000 0.150 0.640
B 0.074 0.083 0.040 0.000 0.240
*P \0.01; yP \0.05.

3
Table IV. Results of Mann-Whitney U tests used to compare volume losses (mm ) occurring on the surfaces on bone-
and tooth tissue–borne sides
Tooth tissue–borne Bone-borne

Surface Mean SD Min Max Mean SD Min Max P value

AL 0.359 0.395 0.000 1.700 0.025 0.019 0.000 0.050 0.001*
AB 0.511 0.430 0.020 1.500 0.050 0.080 0.000 0.240 \0.001y
ML 0.347 0.522 0.000 1.430 0.019 0.037 0.000 0.120 0.021z
MB 0.676 0.637 0.000 1.980 0.009 0.018 0.000 0.060 \0.001y
CL 0.055 0.070 0.000 0.180 0.010 0.021 0.000 0.070 0.157
CB 0.300 0.513 0.000 1.450 0.015 0.026 0.000 0.080 0.035z
*P \0.01; yP \0.001; zP \0.05.

the bone-borne side. Significantly more resorption was
found on the tooth tissue–borne side than on the
bone-borne side (P \0.05).
DISCUSSION
In conventional RME methods, the applied forces are
transmitted to the sutures by way of the teeth and
palatal mucosa, thus leading to expansion. However,
undesirable complications, such as buccal tipping, root
resorption in the teeth, fenestrations in the buccal
bone, and gingival recessions, may occur during this
force transmission. To avoid these effects, orthodontists
have introduced “bone-borne RME” appliances that
receive support from the bone in the palatal region
instead of from the teeth. Researchers have placed
distractors on the bone with this method, but the use
of distractors has not become widespread, because
they are expensive, invasive, and unhygienic. Subse-
quently, various appliances have been designed that
use noninvasive and cheap miniscrews, and they have
become widely implemented.16
Root resorption occurring during tooth movement is
affected by genetic17 and systemic18 factors. In the
present split-mouth study, the effect of 2 different
methods on the roots was examined by inserting different
appliances on the right and left sides of the same patient
to minimize the possibility that individual differences
would confound our results. Ho et al19 stated that the
right and left upper first premolar teeth gave similar
resorption results, such that these teeth can act as con-
trols for each other. That investigation19 was taken into
consideration in the planning of our study approach.
The regions where the maximum resorption was
observed in the teeth on the side treated with
tooth-borne RME were the MB and AB surfaces. The
amount of resorption was significantly greater on those
surfaces than on the CL surface. When we examined the
teeth by separating them into 3 horizontal regions
(apical, middle, and cervical thirds), it was found that
most of the resorption occurred in the middle third,
followed by the apical third, and the amount of volume
loss was significantly more in those 2 regions than in the
cervical third. When we analyzed the buccal and lingual
surfaces separately, the amount of resorption was
significantly more on the buccal surface than on the
lingual surface. These findings are consistent with those
of previous studies.8,20-22

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188 Yildirim and Akin

3
Table V. Results of Mann-Whitney U tests used to compare volume losses (mm ) occurring on the apical, middle, and
cervical thirds and the lingual and buccal sides between the tooth tissue–borne and bone-borne groups
Tooth tissue–borne Bone-borne

Surface Mean SD Min Max Mean SD Min Max P value

Third A 0.871 0.720 0.020 3.020 0.075 0.094 0.000 0.290 \0.001*
M 1.023 1.047 0.000 2.910 0.028 0.045 0.000 0.140 \0.001*
C 0.355 0.535 0.000 1.580 0.025 0.030 0.000 0.080 0.017y
Side L 0.761 0.667 0.000 2.200 0.054 0.051 0.000 0.150 \0.001*
B 1.487 1.112 0.060 4.230 0.074 0.083 0.000 0.240 \0.001*

*P \0.001; yP \0.05.

3
Table VI. Results of Mann-Whitney U tests used to compare the volumetric (mm ) and percentage (%) total volume
losses occurring in teeth between the tooth tissue-borne and bone-borne groups
Tooth tissue–borne Bone-borne

Loss Mean SD Min Max Mean SD Min Max P value

Volume (mm3) 2.249 1.552 0.550 5.550 0.128 0.113 0.000 0.340 \0.001*
Percentage (%) 6.285 5.019 1.480 19.120 0.392 0.353 0.000 1.000 \0.001*
*P \0.001.

In the side treated with bone-borne RME, it was
determined that significantly more resorption occurred
on the AL surface (0.025 mm3) than on the MB surface
(0.009 mm3). As presented in Table II, the maximum
average value observed on the AB surface was
0.050 mm3. However, the probable reason for this
change not reaching statistical significance is that the
median value of the AB group (0.015 mm3) was lower
than that of the AL group (0.020 mm3). Because the
statistical analysis was performed with the use of
nonparametric tests in this study, the group with the
highest crater volume was determined by the median
value, not the mean value. Consequently, when the
bone-borne side was evaluated within the group, a
higher amount of resorption was seen to occur on the
AL and AB surfaces than on the other surfaces.
Segal et al23 reported that the amount of root
resorption occurring in the apical region was
significantly more than in the middle and cervical
regions. They observed that the amount of resorption
occurring in the apical region of the tooth was directly
associated with the amount of movement of this region
within the bone. Feller et al24 attributed the greater
amount of root resorption in the apical region to the
following reasons: the presence of a thicker and more
rigid bone in the apical region, despite the presence of
a thinner and more flexible bone structure in the cervical
third region, the fact that the forces transmitted to the
root during tooth movement were concentrated in a
narrower region in the apical third region than in
the cervical third, and a greater force per unit of surface
area.
The reason for the excessive resorption craters on the
buccal surfaces is that the force was applied to the tooth
in the buccal direction. Simultaneously, compression
occurs on the buccal surfaces of the root, while tension
occurs on the lingual surfaces. Root resorption may
occur during the elimination of the hyalinization tissue
on the compressed side.25
In the between-group evaluations of the tooth roots
in the 6 regions, the root resorption occurring on all
surfaces, except for the CL surface, was significantly
more on the tooth tissue–borne side than on the
bone-borne side. The AB and MB surfaces showed
greater changes between the tooth tissue–borne group
and bone-borne group (P \0.001). The lack of
statistically significant differences in root resorption on
the CL surface between the groups is likely because the
CL surface was the least affected by the force.
When the amounts of root resorption on the apical,
middle, and cervical third surfaces of the tooth
tissue–borne and bone-borne groups were compared,
the amount of root resorption on all surfaces was found
to be significantly higher in the tooth tissue–borne
group than in the bone-borne group. No significant
differences were found on the buccal and lingual
surfaces. These results are consistent with the findings
of previous studies,4,10,26 which found that the
resorption that may occur in the roots of the teeth
may be reduced by means of RME appliances receiving

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Yildirim and Akin
support from both teeth and tissues. Other researchers
have designed novel RME appliances that receive
support from miniscrews placed in the palatal region
instead of receiving support from the teeth.3,27,28 They
aimed to decrease the dental effects of RME treatment
by removing the tooth support of the appliance, thus
eliminating the forces that cause undesirable effects
on the teeth. Some of these undesirable effects are
buccal fenestration of the roots, buccal tipping of the
teeth, gingival recession, and root resorption. Our
results confirm the hypotheses of those researchers.
When the total volume losses occurring in the teeth
were examined, the volume losses in this study were
2.249 mm3 and 0.128 mm3 in the tooth tissue–borne
and bone-borne groups, respectively. The resorption
rates determined by percentage were 6.285% in the
tooth tissue–borne group and 0.392% in the
bone-borne group. In previous studies, volume losses
of 7.21%10 and 4.76%11 were found in the first premolar
teeth. The percentages of root resorption obtained in
those studies were found to be similar to those of the
tooth tissue–borne side in our study.
The 2D images of the teeth, obtained with the use
of a micro-CT device, were reconstructed into 3D im-
ages with the use of the Mimics program. That pro-
gram can calculate the whole root volume of the
teeth by separating it into regions. The volume of
the teeth was again calculated with the use of the
same methods after the process of filling the resorbed
areas. Thus, initial volumes can not be measured
before treatment. To minimize the occurrence of this
situation, individuals without previously orthodontic
treated and systemic disease were included in our
study. The resorption volumes found with the use of
this program are calculated by filling only the resorp-
tion craters occurring in the roots of the teeth. There-
fore, the resorption areas that may occur, especially in
the buccal areas, are not crater shaped, but are more
inclusive and distort the root contours. Furthermore,
the root length shortening that may occur in the apical
regions could not be evaluated in our study. In addi-
tion, the resorption that may be present in the teeth
before the treatment can not be determined during
drawing. Simultaneously, although the teeth were ex-
tracted by precise surgical methods and controlled af-
ter the extraction, the total volume of the teeth may
have decreased by a small amount owing to possible
fractures in the apical region that were too small to
be seen. These are some of the factors that make it
difficult to obtain precise results in calculating the
volume of the resorbed regions. These are the main
limitations of our methodology, which will persist
American Journal of Orthodontics and Dentofacial Orthopedics
189
until technology for intraoral micro-CT imaging is
developed.
CONCLUSIONS
In the tooth tissue–borne RME side, more resorption
was observed on the buccal surface than on the lingual
surface, and more resorption was observed in the apical
and middle thirds than in the cervical third. In contrast,
in the bone-borne RME side, root resorption was
observed even though support was not provided by the
teeth. However, this resorption was not exhibited in
significant quantities. Significantly more root resorption
occurred in the tooth tissue–borne RME treatment
group than in the bone-borne RME group. When
maxillary transverse deficiency was treated with the
use of tooth tissue–borne RME, more root resorption
occurred in the cervical, middle, and apical thirds and
on the buccal and lingual sides than with the use of
bone-borne RME. Bone-supported appliances for RME
treatment may decrease the amount of potential root
resorption, which represents an advantage compared
with tooth tissue–borne appliances.
ACKNOWLEDGMENTS
Supported by a grant from Selcuk University founda-
tion (number: 15102046). The authors are grateful to Dr.
Ayse Menzek and research assistant Ece Bayir for their
helpful suggestions.
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